随着人口老龄化及慢性病负担加重，康复医疗需求大幅增加。我国现行的疾病诊断相关分组（DRG）或病种分值付费（DIP）医保支付方式与康复医疗特点不完全兼容，无法满足康复患者的需求;按床日付费也存在过度医疗等问题。在此背景下，南京市借鉴国际国内经验，推出康复病组价值付费（VRG）模式。本研究首先分析国内外已有的康复支付实践经验，总结构建价值导向康复支付体系的思路，进而详细阐述南京市VRG的设计理念与运作机制，并介绍其价值支付体系，最后结合南京市数据进行初步效果分析，总结改革成果与不足，并提出完善思路，以期为我国康复医保支付方式改革提供有益借鉴。
Abstract
With an ageing population and increasing burden of chronic diseases, demand for rehabilitation services has surged. However, the current Diagnosis-Related Groups (DRG) /Big Data Diagnosis-Intervention Packet (DIP) payment system is not fully compatible with the characteristics of rehabilitation care. Meanwhile, per-diem payment systems have given rise to issues such as over-treatment. Against this backdrop, Nanjing City has drawn upon international and domestic experience to introduce the Value-based Rehabilitation Groups (VRG) payment model. The article first analyses existing rehabilitation payment practices globally and domestically, summarising approaches to establishing value-oriented rehabilitation payment systems. It then details Nanjing City's VRG design philosophy and operational mechanisms, and the value-based payment framework is introduced, alongside a preliminary effectiveness analysis using data from Nanjing City. Finally, it summarises the reform's achievements and shortcomings while proposing refinement strategies, aiming to provide valuable insights for China's rehabilitation medical insurance payment reforms.
关键词
康复医疗 /
医保支付 /
价值导向 /
VRG
Key words
rehabilitation care /
medical insurance payment /
value orientation /
VRG
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参考文献
[1] ZHANG L, SUN L.Impacts of diagnosis-related groups payment on the healthcare providers' behavior in China: a cross-sectional study among physicians[J]. Risk manage health policy, 2021,1(14):2263-2276.
[2] KHIAOCHAROEN O, PANNARUNOTH
AI S, ZUNGSONTIPORN C.Cost of acute and subacute care for stroke patients[J]. The journal of the Medical Association of Thailand, 2012,95(10):1266-1277.
[3] SALA S, SOONTORNPIPIT P.Design and development of data model for Thai sub acute and non acute patients[J]. Applied mechanics and materials, 2015,781:579-582.
[4] JINXUAN Z, QIUPING M.Meta-analysis of nursing stroke survivors in convalescence in China in recent ten years[J]. Chinese clinical nursing, 2019,11(5):449-451.
[5] 胡琳琳,支梦佳,黄春芳,等.急性后期医疗服务医保支付方式的美国经验与启示[J].中国医疗保险,2021(10):75-80.
[6] MCGARRY BE, WHITE EM, RESNIK LJ, et al.Medicare's new patient driven payment model resulted in reductions in therapy staffing in skilled nursing facilities[J]. Health affairs, 2021,40(3):392-399.
[7] 杜天天,刘跃华,杨燕绥.美国专业护理机构以患者为导向的病例分组支付方式研究——从RUG到PDPM[J].中国卫生政策研究,2020,13(06):73-80.
[8] 李曼. 美国康复医保支付方式的发展与启示[J].中国卫生经济,2021,40(11):89-92.
[9] SCHELLER-KREINSEN D, QUENTIN W, GEISSLER A, et al.DRG-type hospital payment systems in Europe: the German G-DRG system and English health care resource groups (HRGs)[M]//England and Germany in Europe - what lessons can we learn from each other?: European Health Care Conference, Nomos Verlagsgesellschaft mbH & Co. KG,2011: 91-110
[10] 郑丽英,朱碧帆,李芬,等.美国和德国长期住院支付方式对我国按床日付费的启示[J].中国卫生经济,2024,43(01):92-96.
[11] 舒乐博,单春雷,刘丽萍,等.德国康复理念及在神经康复领域的应用[J].中国康复,2024,39(04):246-250.
[12] 胡琳琳,龙飞,李佳,等.康复病组按价值付费的“长沙模式”[J].中国医疗保险,2022(6):74-79.
[13] 王庆,吴宏,程静.我国急性后期康复护理医保支付改革试点的典型模式比较分析[J].经济研究导刊,2024(17):128-132.
[14] 李蓓,胡琳琳.长沙市康复住院医保支付方式改革效果分析[J].中国卫生经济,2024,43(04):6-9.
[15] 胡琳琳,邵宁军,支梦佳,等.急性后期康复护理医保支付制度改革的实践探索——以浙江省金华市为例[J].卫生经济研究,2021,38(12):11-15+19.
基金
南京市医疗保险研究会基金“南京VRG支付政策研究”（NJYB2025ZWH003）。
